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Rehabilitation Practices

Summary

There is level 3 evidence (from predominately American studies: DeVivo et al. 1990; Heinemann et al. 1989; SA. 1999; Whiteneck et al. 2011; Whiteneck et al. 2012; Woolsey 1985; Yarkony et al. 1987; Yarkony et al. 1990) that rehabilitation LOS has become progressively shorter between 1973 and 2009. For other countries, only investigators from Israel (Ronen et al. 2004) have published data in a single report that is consistent with this trend.

There is level 3 evidence (based on several studies: Chan & Chan 2005; DeVivo et al. 1990; Tooth et al. 2003; Whiteneck et al. 2011; Whiteneck et al. 2012) that those with higher level and more severe injuries have longer rehabilitation LOS.

There is level 4 evidence that a significant proportion of people (~50%) initially assessed as AIS B and C will improve by at least one AIS grade in the first few months post-injury concomitants with inpatient rehabilitation. Fewer individuals (~10%) initially assessed as AIS A and D will improve by one AIS grade.

There is level 4 evidence that individuals make significant functional gains during inpatient rehabilitation, more so for those with complete and incomplete paraplegia and incomplete tetraplegia.

There is level 4 (from one case series: Heinemann et al. 1995) that increased therapeutic intensity may not be associated with functional benefit as measured by the Functional Independence Measure.

There is level conflicting level 5 evidence (from one observational study and one post-hoc analysis: Kapadia et al. 2014; Whiteneck et al. 2012) that increased therapeutic intensity may be associated with increased functional benefit (as measured by the FIM and SCIM), independence, social integration, reduced hospitalizations, and pressure ulcer incidence.

There is level 5 evidence (from one observational study: Whiteneck et al. 2011) that treatment times and intensities vary extensively between patients and may be associated with length of stay, rather than patient, injury, or clinician characteristics.

There is level 3 evidence (from four case control studies: Cifu, Huang et al. 1999; Cifu, Seel et al. 1999; Osterthun et al. 2009; Seel et al. 2001) that shorter rehabilitation LOS is associated with younger versus older individuals with paraplegia. The same may not be true for those with tetraplegia or for mixed cohorts involving traumatic and non-traumatic SCI.

There is level 3 evidence (from four case control studies: DeVivo et al. 1990; Kennedy et al. 2003; Scivoletto et al. 2003; Yarkony et al. 1988; and one observational study: Marco Franceschini et al. 2020) that age is inversely related to patient’s independence level.

There is level 3 evidence (from five case control studies: Cifu, Huang et al. 1999; Cifu, Seel et al. 1999; Kennedy et al. 2003; Scivoletto et al. 2003; Seel et al. 2001) that younger as compared to older individuals are more likely to obtain greater functional benefits during rehabilitation.

There is level 3 evidence (from two case control studies: Kennedy et al. 2003; Scivoletto et al. 2003) that significant increases in neurological status during rehabilitation are more likely with younger than older individuals with tetraplegia or for mixed cohorts involving traumatic and non-traumatic SCI. The same may not be true for those with paraplegia.

There is conflicting level 3 evidence (from three case control studies: Gupta et al. 2008; McKinley, Huang et al. 1999; McKinley et al. 2002) that older individuals are more likely to experience a non-traumatic than traumatic SCI.

There is level 4 evidence (from one case series: Tchvaloon et al. 2008) that older individuals are more at risk of developing pressure sores.

There is level 4 evidence (from two case series: Anzai et al. 2006; New 2005) that older individuals are more likely to be discharged to an extended care unit.

There is level 4 evidence (from one case series: Eastwood et al. 1999) that age may be associated with a longer length of rehabilitation stay.

There is level 4 and 5 evidence (from two case series and one observational study: Furlan & Fehlings 2009; Pollard & Apple 2003; van der Putten et al. 2001) that younger patients are more likely to experience improved motor outcomes when compared to older individuals. However, both groups experience similar sensory deficits.

There is level 5 evidence (from one observational study: Ronen et al. 2004) that age has no effect on the length of acute hospital stay.

There is level 3 evidence (from five case control studies: McKinley et al. 2008; McKinley, Huang et al. 1999; McKinley et al. 2001; McKinley et al. 2002; Yokoyama et al. 2006) that those with non-traumatic SCI have generally reduced rehabilitation LOS and reduced hospital charges.

There is level 3 evidence (from one case control study: Dionne et al. 2020); level 4 evidence (from two case series: Citterio et al. 2004; McKinley et al. 1996); and level 5 evidence (from two observational studies: Marco Franceschini et al. 2020; Halvorsen et al. 2019a) that those with non-traumatic SCI have similar discharge destinations as compared to those with traumatic SCI.

There is conflicting level 3 evidence (from seven case control studies: Gupta et al. 2008; McKinley et al. 2008; McKinley et al. 2001; McKinley et al. 2002; Ones et al. 2007; Yokoyama et al. 2006) that individuals with non-traumatic SCI may experience less functional gains than those with traumatic SCI, although many studies are comparing persons with different etiologies of non-traumatic SCI.

There is level 3 evidence (from one case control study: Bradbury et al. 2008) that individuals with traumatic SCI with or without concomitant traumatic brain injury have similar LOS and achieve similar FIM motor scores, but associated costs were higher in those with dual diagnosis.

There is level 4 evidence (from one case series study: van der Putten et al. 2001) that those with non-traumatic SCI are more likely to be older, female, have paraplegia, and have an incomplete injury as compared to those with traumatic SCI.

There is conflicting level 4 evidence (from four case series: Citterio et al. 2004; Gupta et al. 2009; McKinley et al. 1996; New 2005) that patients with non-traumatic SCI recover significant neurological and functional improvements following rehabilitation.

There is conflicting level 3 (from three case control studies: Greenwald et al. 2001; Ronen et al. 2004; Scivoletto 2004); level 4 evidence (from four case studies: Furlan et al. 2005; New 2005; Pollard & Apple 2003; Sipski et al. 2004); and level 5 evidence (from one observational study: Marco Franceschini et al. 2020) that there is no difference with respect to the gender on discharge destination, rehabilitation LOS and neurological or functional outcomes associated with rehabilitation.

There is conflicting level 3 (from four case control studies: Gupta et al. 2008; McKinley et al. 2008; McKinley et al. 2002; Giorgio Scivoletto et al. 2004); and level 4 evidence (from one case series: Sipski et al. 2004) that male patients experience more traumatic and incomplete injuries and of those that are female, younger females experience more complete injuries.

There is conflicting level 4 evidence (from one case series: Furlan et al. 2005) that women may experience more complications at admission, psychiatric complications, and deep vein thrombosis than men.

There is level 5 evidence (from one observational study: Krause et al. 2006) that female patients utilize more nonroutine physician visits than males.

There is level 3 evidence (from one case control study: Gupta et al. 2008) that socioeconomic status has no effect on the type of injury.

There is level 5 evidence (from one observational study: Chhabra & Bhalla 2015) that financial constraints experienced by patients affect access to SCI care in all socioeconomic status groups, except those with the greatest socioeconomic status.

There is level 3 (from two case control studies and three case series: Eastwood et al. 1999; Krause et al. 2006; Meade, Cifu et al. 2004; Pollard & Apple 2003; Putzke et al. 2002) that there is no difference with respect to race (Caucasians versus African-American) on rehabilitation LOS and neurological or functional outcomes associated with rehabilitation that are not otherwise explained by socio-demographic or etiological differences.

There is level 3 evidence (from three case control studies: Heinemann et al. 1989; Tator et al. 1995; Yarkony et al. 1985) that individuals cared for in interdisciplinary, specialist SCI acute care units soon after injury (most being admitted within 48 hours) begin their rehabilitation program earlier.

There is level 3 evidence (from one case control: Donovan et al. 1984); and level 5 evidence (from one observational study: Smith 2002) that individuals cared for in interdisciplinary, specialist acute care SCI units have fewer complications upon entering and during their rehabilitation programs.

There is level 2 evidence (from two cohort studies: McKechnie et al. 2019; Pattanakuhar et al. 2019); level 3 evidence (from one case control study: Heinemann et al. 1989); and level 4 evidence (from one pre-post test: Chang et al. 2020) that individuals cared for in interdisciplinary, specialist SCI units make more efficient functional gains during rehabilitation (i.e., more or faster improvement).

There is level 3 evidence (from one case control study: Tator et al. 1995) that individuals cared for in interdisciplinary, specialist SCI units have reduced mortality.

There is level 2 evidence (from one cohort study: Cheng et al. 2017) that individuals who receive inpatient rehabilitation in specialist SCI rehabilitation units are more likely to be discharged home than those who do not.

There is level 3 evidence (based on several retrospective, case-control studies) that individuals admitted earlier to interdisciplinary, integrated specialist SCI units have a shorter total hospitalization length of stay than those admitted later.

There is level 3 evidence (based on several retrospective, case-control studies) that individuals admitted earlier to interdisciplinary, integrated specialist SCI units make greater functional gains in a shorter period of time (i.e., greater efficiency) than those admitted later.

There is level 3 evidence (based on several retrospective, case-control studies) that individuals admitted earlier to interdisciplinary, integrated specialist SCI units have fewer secondary medical complications (especially pressure sores) than those admitted later.

There is level 4 evidence (based on case series studies) for the positive utility of admission to rehabilitation even at delays ≥90 days post-injury.

Because of the variability between studies as to what constitutes “early” admission to interdisciplinary, specialist-integrated SCI units, it is not possible to determine a specific period for optimal admission. At least one study has demonstrated benefits with an early admission described as £30 days post-injury. The majority of studies defined early admissions as 1-2 weeks post-injury, while studies focused on acute care describe early admission as within 24 hours post-injury.

There is Level 2 evidence (from a randomized controlled trial: Dallolio et al. 2008) supported by level 4 evidence (from one prospective controlled trial: Phillips et al. 1999; and one pre-post test: Shem et al. 2017) that telerehabilitation is clinically feasible and may be an adjunct to routine follow-up care for a variety of secondary health complications, leading to improved patient satisfaction and enhance functional outcomes.

There is level 5 evidence (from one observational study: Kim et al. 2012) that clinicians and individuals with SCI are interested in telerehabilitation, although, some concerns exist regarding the cost and risks (i.e., medical liability) of implementation.

There is limited level 4 evidence (from one prospective controlled trial: Dunn et al. 2000) that provision of routine, comprehensive, specialist follow-up services may result in perceived improvements in health, independence, and fewer feelings of depression.

There is limited level 4 evidence (from one prospective controlled trial: Bloemen-Vrencken et al. 2007) that coordination of care through a community-based transmural nurse has no effect on reducing secondary complications and associated health utilization as compared to routine outpatient care consisting of periodic visits to a specialized rehabilitation doctor or center.

There is level 4 evidence (from one pre-post test: Lugo et al. 2007) that regular and accessible interdisciplinary follow-up can result in achieving functional goals where protocolized SCI care is unavailable.

There is level 4 evidence (from one pre-post test: Derakhshanrad et al. 2015) that multidisciplinary outpatient rehabilitation programs may complement inpatient rehabilitation programs and promote functional recovery.

There is level 4 evidence (from one pre-post test: Zinman et al. 2014) that there is a need for community reintegration programs following SCI, however, further research is necessary to determine the efficacy of such programs.

Across several studies there is level 2 evidence (from one cohort study: Cai et al., 2020); level 3 evidence (from one case control study: Dryden et al. 2004); level 4 evidence (from seven case series: Charlifue et al. 2004; Dorsett & Geraghty 2008; Franceschini et al. 2003; Jaglal et al. 2009; Middleton et al. 2004; Paker et al. 2006; Savic 2000); and level 5 evidence (from one observational study: Cardenas et al. 2004) that hospital readmission is a significant issue for individuals with SCI in all regions.

There is level 5 evidence (from two observational studies: Cardenas et al. 2004; Charlifue et al. 2004); and level 4 evidence (from one case series: Middleton et al. 2004) that hospital re-admission rates are highest in the first year post-injury and then tend to decline in the first two years following injury.

There is level 4 evidence (from two case series: Dorsett & Geraghty 2008; Jaglal et al. 2009) that rehospitalization rates stabilize at a significantly high rate over time.

There is level 2 evidence (from four cohort studies: Mashola et al. 2019; Ruediger et al. 2019; Sharwood et al. 2019; Skelton et al. 2019); level 3 evidence (from one case control: Dryden et al. 2004) supported by level 4 evidence (from 6 case series: Dorsett & Geraghty 2008; Franceschini et al. 2003; Jaglal et al. 2009; Middleton et al. 2004; Paker et al. 2006; Savic 2000); and level 5 evidence (from one observational study: Cardenas et al. 2004) that urinary problems (UTIs), pressure ulcers, respiratory infections, and musculoskeletal problems are consistently among the most frequent causes of emergency department visits and hospital readmissions in persons with SCI.

There is level 4 evidence (from three case series: Charlifue et al. 2004; Jaglal et al. 2009; Middleton et al. 2004); and level 5 evidence (from two observational studies: Cardenas et al. 2004; Sippel et al. 2019) that factors such as increased age, lower motor function, greater severity of the injury, prior contact with the health system, rural habitation, mental health comorbidities and being unmarried are associated with a greater risk of hospital readmission.

There is level 3 evidence (from one case control study: Guilcher et al. 2010) supported by level 5 evidence (from two observational studies: Guilcher et al. 2013; Munce et al. 2009) that several factors are associated with a greater likelihood of physician visits including older age, lower FIM scores, discharge to chronic care or other rehabilitation facilities, rural residence, comorbidities or in-hospital complications.

There is level 3 evidence (from one case control study: Dryden et al. 2004) supported by level 5 evidence (from one observational study: Amsters et al. 2014) that persons with SCI have an increased number of physician contacts as compared to matched controls from the general population, especially in the first year post-injury.

There is level 5 evidence (from four observational studies: Amsters et al. 2014; Donnelly et al. 2007; Munce et al. 2009; Noonan et al. 2017) that individuals with chronic SCI seek out family physicians rather than specialists, irrespective of country. However, many critical health concerns (e.g., sexual health, emotional issues, or community reintegration) are not addressed by family physicians or specialists.

There is level 5 evidence (from one observational study: Guilcher et al. 2013) that emergency departments are often used as an improper substitute for primary care in individuals with SCI, particularly in rural areas, reflecting a lack of access to care for preventable conditions.

There is level 5 evidence (from four observational studies: Donnelly et al. 2007; Jakimovska et al. 2017; Noreau et al. 2014; Stillman et al. 2014) that a significant proportion of individuals with SCI experience accessibility barriers during physician visits, and do not receive routine screening or preventative testing and are not satisfied with the services received.

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